A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Expresses that they cannot get enough air to breathe.

Respiratory rate of 7 breaths/minute.

Bilateral wheezing on auscultation.

Pulse oximeter reading of 89% on room air.

Answer and Explanation

The Correct Answer is B

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Answer: D. Antiretroviral medication prevents the transmission of the virus.

Rationale:

A. The viral load can be decreased to an undetectable level:
This statement reflects an accurate understanding of antiretroviral therapy. Effective treatment can reduce the viral load to undetectable levels, which is a key goal of HIV treatment, allowing individuals to live healthier lives and reducing the risk of transmitting the virus to others.

B. HIV infection is not cured by the antiretroviral regimen:
This statement is also accurate. Antiretroviral therapy (ART) effectively manages HIV infection but does not cure it. Patients need to remain on medication for life to control the virus and maintain their health.

C. The medications can decrease acquired AIDS-related complications:
This statement is correct as well. Antiretroviral medications can help manage HIV and prevent the progression to AIDS, thereby reducing the likelihood of complications associated with AIDS, such as opportunistic infections.

D. Antiretroviral medication prevents the transmission of the virus:
This statement requires additional instruction because, while effective antiretroviral therapy can significantly reduce the risk of transmission, it does not entirely prevent it. Patients with an undetectable viral load have a greatly reduced risk of transmitting HIV to sexual partners (often summarized as "U=U" or "Undetectable = Untransmittable"), but it is crucial to understand that there is still a small risk involved. Therefore, additional education is necessary to clarify the need for continued safe practices, such as using condoms, even when on effective therapy.

A. Avoid taking the medication on an empty stomach. B. Maintain a fluid intake of 1,500 to 3,000 mL per day. C. Report fluctuations in weight to the healthcare provider. D. Keep medication fliers for frequent review and reference.

Correct Answer is B

Explanation

A) Avoid taking the medication on an empty stomach:
While it’s generally recommended to take lithium carbonate with food or milk to minimize gastrointestinal side effects, taking it on an empty stomach does not pose a significant risk. Therefore, it is not the most crucial instruction to emphasize to the client.

B) Maintain a fluid intake of 1,500 to 3,000 mL per day:
This instruction is crucial because lithium can cause dehydration, especially if the client becomes dehydrated due to increased sweating or decreased fluid intake. Adequate fluid intake helps maintain stable lithium levels in the blood and reduces the risk of toxicity. Emphasizing the importance of maintaining hydration is essential for clients taking lithium.

C) Report fluctuations in weight to the healthcare provider:
Weight fluctuations can indicate changes in fluid balance or other metabolic effects of lithium. While it’s important for the client to report changes in weight, this instruction is not as critical as ensuring adequate fluid intake, which directly affects lithium levels and toxicity risk.

D) Keep medication fliers for frequent review and reference:
While it’s helpful for clients to have medication information for reference, this instruction is more about general medication adherence and education rather than a specific requirement related to lithium carbonate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client who has been diagnosed with HIV about the antiretroviral medication regimen. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Rationale:

The nurse is providing medication teaching to a client with bipolar disorder who receives a prescription for lithium carbonate. Which instruction should the nurse emphasize with the client?

Correct Answer is B

Explanation

The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

The healthcare provider prescribes propylthiouracil (PTU) and Lugol’s solution, a strong iodine solution, for a client with hyperthyroidism. How should the nurse schedule the administration of these medications?

Which assessment finding indicates to the nurse that the prescription bethanechol is effective for a client diagnosed with urinary retention?

A client with plaque psoriasis receives a new prescription for betamethasone valerate lotion. Which instruction should the nurse include in client teaching?

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers?